Epidemiology and current status of allergic rhinitis and asthma in Thailand- ARIA Asia-Pacific Workshop Report.

The allergic diseases of the airway, i.e. allergic rhinitis and asthma, are on the increase in Thailand and their prevalence shows no signs of abating. When compared with a previous study, the incidence of wheezing had increased 4 fold (from 4.2% to 18.3%), and allergic rhinitis increased nearly 3 fold (from 17.9% to 44.2%). The results of the ISAAC phase III study revealed that the frequency of allergic diseases of the respiratory tract in-creased significantly from the ISAAC phase I survey performed in 1995; i.e. asthma increased from 12.2% to 14.5%, and allergic rhinitis from 37.9% to 50.6%. Allergic rhinitis exerts a major impact on the quality of life of Thai patients. The results of skin prick testing have indicated the leading causes of indoor (house-dust mites, house dust, cock-roaches, dogs and cats) and outdoor pollen (Bermuda grass, para grass, sedge, careless weed) allergens. Molds (represented by Cladosporium), although prominent in an aeroallergen survey, returned a low percentage of posi-tive skin prick reactions, and therefore, were considered low in allergenicity. In Thailand, there are clinical practice guidelines for both allergic rhinitis and asthma which are comparable to the international guidelines like ARIA and GINA. Sufficient kinds of pharmacotherapy are on the National List of Es-sential Drugs. Yet due to the limited number of trained allergists, many patients are seen by general physicians, and often, the appropriate diagnostic tests and treatments are not provided. In addition, the financial burden for quality health care may be prohibitive for those without private health insurance in spite of the implementation of a universal health care system for all Thai citizens, which is less than optimal.

Allergic conjunctivitis.

The purpose of this research is to study the clinical features and risk factors of various types of allergic conjunctivitis. Four hundred and forty-five patients with a history of itching, foreign body sensation, lacrimation and red eyes were examined, and a skin test was performed and assessed to grade the severity. The mean age of the subjects was 24.5 +/- 16.3 years with female preponderance, except for vernal keratoconjunctivitis. The majority of the patients had perennial allergic conjunctivitis. Ninety-five percent of the patients had associated allergic diseases, especially allergic rhinitis. Sixty-six percent of the patients had a family history of atopy. Most patients had symptoms at night. Symptoms persisted throughout the year and were generally triggered by exposure to house dust. The allergy skin tests to common aero-allergens were positive in 95% of patients tested. Common allergens causing sensitization were house-dust mites, house dust, cockroaches, and grass pollen. Environmental control and avoidance of these allergens should be stressed in the management of these conditions.

A non-comparative trial of the efficacy and safety of fexofenadine for treatment of perennial allergic rhinitis.

An open-label, non-comparative study was performed in three Otolaryngology centers in Bangkok, Thailand, to assess the efficacy, safety and tolerability of fexofenadine in Thai patients with perennial allergic rhinitis. Altogether 101 perennial allergic rhinitis patients were included, 33 males and 68 females. Mean age was 33 years, average duration of symptoms was 6 years. All patients received fexofenadine hydrochloride 120 mg once daily (OD) in the morning for 2 weeks. Patients recorded their allergy symptoms daily using a 5 point rating scales in the diary card. At the end of 2 weeks, patients and investigators assessed the overall efficacy of treatment. Adverse events and onset of symptom relief were also recorded by every patient. Blood test and ECG were performed before and after treatment in one center (Siriraj Hospital). Total symptom scores and nasal scores decreased significantly from a baseline at 1 week and 2 weeks after treatment (p < 0.05). The mean onset of symptom relief was 2 hours and 12 minutes. The global assessment of the treatment by patients and investigators showed significant concordance. There was no significant change in either the vital signs, laboratory tests or ECG. The incidence of treatment related adverse events was 8% but all were mild and easily tolerated. Drowsiness was reported from only one patient. This study suggests that fexofenadine 120 mg once daily was an effective, safe and well tolerated treatment for perennial allergic rhinitis in Thai patients.

Epidemiology of rhinitis in Thais: characteristics and risk factors.

A questionnaire survey was performed on 3,124 subjects living in Bangkok and its vicinity. The cumulative prevalence of chronic rhinitis (CR) was 13.15% (95% CI = 13.13-13.17). The characteristics of CR subjects, i.e. age group, current occupation, associated allergy, family history of atopy, cigarette smoking and drinking habits were totally different from the non CR group, except for sex preponderance. The possible risk factors for developing CR in this group were high income occupation, presence of associated allergy, family history of atopy, smoking and drinking habits. When CR subjects were further classified into "allergic" and "non-allergic" CR groups by using the presence of associated eye symptoms and known provoking factors as the differential criteria, there was no significant difference in all parameters compared between the two groups, i.e. age, sex, current occupation, associated allergy, family history of atopy, smoking and drinking habits, frequency of occurrence of each nasal symptom, seasonal variation of the symptoms, effect of moving to live in the big city, presence of pets in the house and effect of changing occupation, except for the number of nasal symptoms which was significantly higher in the "allergic" CR group.

Nasal endoscopic findings in patients with perennial allergic rhinitis.

Nasal endoscopy was carried out in 83 patients with perennial allergic rhinitis to evaluate endonasal anatomic variation and to find the correlation between the symptoms of patients and the endoscopic findings. All of the patients had nasal symptoms, 7.2% of the patients were runner, 7.2% were blocker and 85.6% were both. 86.75% of the patients had allergy-related symptoms, i.e. throat symptoms (73.5%), sinus headache (50.6%), and smell disturbance (10.8%). 95.2% of patients had abnormal endoscopic findings, i.e. deviated nasal septum (72.3%), abnormal middle turbinate (49.4%), narrowing of the entrance into the frontal recess (30.1%), septal spur (25.3%), obstruction of the entrance into the frontal recess (19.3%), nasal polyps (15.7%), mucopurulent discharge (14.5%), inferior turbinate hypertrophy (10.8%), abnormal uncinate process (9.6%), abnormal ethmoid bullae (7.2%), and enlargement of aggar nasi cells (2.4%). There was no significant correlation between each symptom and each endoscopic finding. However, there was a significant correlation between sinus headache and all of the combined abnormal endoscopic findings (P<0.05). These findings suggested that variations in endonasal anatomy was not by itself a pathology or a cause of symptoms. However, a combination of these variations may narrow the cleft of the ostiomeatal unit and cause contact area or stenosis, which predisposed patients to persistent symptoms, recurrent infection or resistance to therapy in patients with perennial allergic rhinitis. The endoscope might be a very useful tool for allergists, immunologists, and rhinologists, who work in the nose to deal with these cases.

A survey of allergic rhinitis in Thais.

The incidence of allergic rhinitis in the Thai population was surveyed in two province, Nan in the North and Khonkean in the North-East Thailand. Histories were taken from all subjects and ENT examinations and allergy skin prick tests to six common aeroallergens were made. Total IgE in serum was also assayed in some. Altogether 649 subjects were included on our survey, 338 were children and 311 were adults. Positive skin prick tests to at least 2 allergens and a history of persistent rhinitis or of other allergic symptoms were considered as criteria to identify atopic persons. According to the above criteria, 134 or 20.68% of them had allergies. The incidence of allergic rhinitis in children and in adults was not much different (20.61% in children and 22.78% in adults). These figures are similar to figures reported from other countries. This has confirmed the general belief that alleries are common world-wide. The prevalence of allergic rhinitis in Bangkok is now being surveyed in order to study the effect of air pollution. This will be reported in the future.

A study of mediator cells in chronic rhinitis patientes by nasal scraping method: The first report in Thais.

A study of mediator cells by nasal scraping method was performed for the first time in Thai population i.e. 154 chronic rhinitis patients and 43 healthy volunteer with no nasal symptoms. There were 67 males and 87 females, ages ranged from 8 – 70 years old with the average of 35.5 in the chronic rhinitis group. In the normal volunteer group, there were 21 males and 22 females, ages ranged from 17 – 74 years old with the average of 35. All chronic rhinitis were skin tested by intracutaneous method to a panel of common inhalants. The result of the skin test we graded into 0 – 4+ If the patients had 2+ – 4+ skin test result, they were classified as having allergic rhinitis (AR), while patients who had 0 – 1 were classified as non-allergic rhinitis (NAR). The average number of basophilic metachromatic cells (BMC) in normal volunteers, AR and NAR patients were 2.35 + 10.73 (0 – 57), 121.74 + 198.73 (0 – 1,177) and 11.33 + 32.05 (0 – 117) cells respectively. This findings confirm that AR patients have more BMC on their nasal surface than NAR patients and normal people. When comparing the average number of BMC according to the skin test result in chronic rhinitis patients we found that the average number of BMC in patients with 0, 2+, 3+ and 4+ skin test results were 11.33 + 32.05, 54.54 + 100.49, 110.00 + 84.68 and 135.71 + 212.54 cells respectively. Statistical analysis showed that the number weaker positive and negative results. The sensitivity of nasal scraping method in diagnosing AR was found to be 61.27 percent with the specificity of 90.91 percent, the positive predictive value was 94.56 percent and the efficiency of test was 69.54 percent. We concluded that the study of BMC by nasal scraping method is easy to perform with minimal trauma to the patient, the instrument used is simple and less expensive, the interpretation of result is also accurate and can be repeated. Therefore this method should be considered as another tool to diagnose AR especially in the place where skin test is not available.

Measurements of the ear pinna in Thais: The first report.

The contour of the normal ear pine was studied in 434 Thai people i.e. 686 ears. The subjects were 219 males and 215 females who had never had sever injury or ear surgery. There age group’s were studied years, 3-5 years and 18-20 years. Four measurements were done i.e. ear width and ear length using a sliding caliper and auriculo-cephalic angle and concho-scaphalic angle using a goneometer. The results of the study revealed that the average ear width in Thais of different age groups differed little : was not much different (2.9 + 0.3 cm. At aged 0 - 2 years, 3.3 + 0.4 cm. At age 18-20 years in males and 2.8 + 0.3 cm. To 3.0 + 0.2 cm. in females. However the average ear height increased significantly with age (4.8 + 0.6 cm. At 0-2 years, 6.2 + 0.2 cm. At 18 -20 years in males and 4.7 + 0.5 cm, 6.1 + 0.2 cm. In females). The average auriculo-cephalic angle increased rapid during the early period. The increment of this angle exceeded 85 per cent of adult size at the age of 3 - 5 years (22.3 + 3.8 degrees, at aged 0 - 2 years, 28.0 + 2.5 degrees at aged 3-5 years, 28.4 + 3.1 degrees at aged 18 - 20 years in males and 21.8 + 3.6 degrees, 27.1 + 2.6 degrees and 28.2 + 1.6 degrees respectively in females). In contrast, the concho-scaphalic angle increased gradually with age (79.0 + 4.9 degrees at age 0 -2 years, 82.1 + 4.1 degrees at aged 18.20 years in males, and 79.4 + 4.6 degrees, 82.2 + 4.2 degrees in females). Statistical analysis of all the measurements of the ear pinna showed that the ear width in man at age 18 -20 years is wider than in women (3.3 + 0.4 cm. Versus 3.0 + 0.2 cm.), the ear height was significantly different (between the sexes) from aged 9 -11 years onward (5.9 + 0.4 cm. Versus 5.6 + 0.4 cm.) but there were no significant differences in either the suriculo-cephalic or the concho-scaphalic angles between males and females. Thai ear measurements when comparined with ear measurements in Caucasians were significantly smaller. This may be attributed to the different body structure of the different races. However, the percentage ratio of ear width to ear height was similar i.e. 50.60 per cent in both populations. The auriculo-cephalic angles in Thais were in the same range as western people.

Triangle of beauty of the face in Thai adults.

In order to evaluate the aesthetic triangle of the face in Tai adults, we measured the vertical nasal height and the lower facial height of 200 subjects by using the sliding caliper. There were 100 males and 100 females who had never had nasal surgery or severe nasal injury. Their ages ranged from 15-65 years old. The mean body height in males was 165.5 + 6.2 cms; in females, 155.4 + 5.2 cms; the mean body weight in males was 58.2 8.0 kgs; in females, 52.4. The study showed that the average vertical nasal height in males was 5.1 + 0.3 cms; in females, 4.8 + 0.3 cms; the average lower facial height in males was 6.6 + 0.4 cms; in females, 6.3 + 0.4 cms. Statistical analysis revealed significant differences of the two parameters measured between males and females. There was significant correlation between the lower facial height with body weight and body height only in Thai males.

Intranasal leprosy granuloma: The first case report in Thailand.

One male patients presenting with symptoms and signs of atrophic rhinitis and chronic sinusitis for one year, there was also a small red mass at anterior end of right middle turbinate. Histopathological section showed that the mass was covered by stratified squamous mucosa with diffuse cellular infiltration of mostly macrophages with clear vacuolated cytoplasm (= foam cells) with few lymphocytes in submucosa. Acid fast stain (modified Fite Feraco stain) showed numerous acid fast bacilli in scatter and in clumps, known as globi pattern mucosa. This is the first case reported in Thailand. Multidrug therapy was given to the patient which conprised of rifampicin 450-600 mg. Once a month, lamprene 300 mg start and then 100 mg. in alternate day with dapsone 100 mg. OD. The aim of this report is to remind the otolaryngologists of the existence of leprosy in the nose and they should be aware of the highly contagious nasal secretion from these patients.

Effect of allerglobuline injection on serum immunoglobulin levels in ENT patients.

Allerglobuline is a human gammaglobulin preparation which has been reported to have a protective effect against Type I allergic diseases and chronic infection of the upper respiratory tract both in adults and children. This study included 64 patients suffering from perennial allergic rhinitis and/or chronic infection of the nose, paranasal sinuses and pharynx. All patients received Allerglobuline 10 ml intramuscular injection once a week for 5 times then once a month for another 3 times. Blood samples were taken before the first and after the last injections to assay for the levels of Igs G, A, M and E. The therapeutic responses were evaluated after the fifth injections by dividing into 5 grades (from Grade I = excellent to Grade V = no response). Statistical analysis revealed that there was no significant difference between the pre- and post-treatment levels of Igs, G, A and M. But the level of IgE decreased significantly after 8 injections (p less than 0.001). There was no correlation between the level of immunoglobulins and grade of therapeutic responses. But the number of patients who respond satisfactorily to Allerglobuline treatment increased from 62.26% after 5 injections to 77.36% after 8 injections. This difference does not reach the statistically significant level but is noteworthy.

A preliminary study of circulating immune complexes during allergen immunotherapy in Thai patients.

Circulating immune complexes are suspected as a potentially serious adverse effect after prolonged allergen immunotherapy. This study was undertaken to determine whether there were any significant immunological differences between 32 subjects with allergic rhinitis/asthma treated with immunotherapy of various durations and 13 subjects with similar diagnosis who had never been treated by immunotherapy. All patients were carefully examined for symptoms and signs of immune-complex diseases with negative results. The presence of circulating immune complexes was evaluated by the modified 125I-C1q binding test, the solid phase conglutinin (K) binding test and determination of C3, C4 and C3d levels. In addition, urinalysis, and quantitative determination of serum IgG, IgA, IgM and IgE were also performed. The overall results suggested that prolonged allergen immunotherapy did not result in an increase of circulating immune complexes or other adverse immunological consequences.

Intranasal budesonide for the treatment of perennial rhinitis in Thai patients.

The efficacy and tolerability of a new intranasal glucocorticosteroid, budesonide, was evaluated in 28 Thai adult patients with perennial rhinitis. After one week pre-treatment observation period, the nasal spray was given as two puffs into each nostril twice daily (400 micrograms/day) for four weeks. The severity of all nasal symptoms decreased significantly after 1 week treatment reaching a minimal level after 2 weeks. The amounts of antihistamine tablets taken by the patients were also significantly reduced during the treatment with budesonide. Three patients reported adverse effects which were mild and easily tolerated. Morning plasma cortisol levels measured before and after four-week treatment in 15 patients revealed no significant changes. This study suggests that intranasal budesonide is an effective and well-tolerated treatment for perennial rhinitis.